The Differential Diagnosis of Right Lower Quadrant Pain

Martin E. Kreis, Franz Edler v. Koch, Karl !alter "auch, Klaus Friese

Right lower quadrant pain #ts diagnostic assess$ent %resents a challenge &ecause the leading entities in the differential diagnosis are different de%ending on the %atient's age and se(. History and physical examination: the key elements of case stratification
The history and physical examination are the key elements leading to the determination of the diagnosis and of the further management of the patient (4, e7). The physician should inquire in general about the onset, duration, nature, and intensity of the pain, as well as about the following specific features ! "efecation has the patient noticed any abnormalities# ! $s the patient suffering from nausea, %omiting, or alguria&dysuria (painful or otherwise abnormal micturition)# $n female patients, a gynecological history is obligatory and often points to the diagnosis. $n taking the history, the physician should always try to gain information of differential diagnostic %alue in order to determine which further tests should be performed. The physical examination ser%es the same purpose. The physician should inspect, auscult, and palpate the abdomen, look for guarding and peritoneal signs, check the renal beds and potential hernia sites, and perform a digital rectal examination. 'emale patients should ha%e an intra%aginal examination as well, as a component of the acute gynecological consultation (e().

Diagnostic testing as an adjunct to clinical examination
Testing with diagnostic apparatus should be performed only after the history and physical examination ha%e been completed. $ts purpose is to confirm the diagnosis that seems most likely among the possible differential diagnoses and to exclude all of the competing diagnoses (box). $f appendicitis is suspected, a blood draw for laboratory testing (e), *) and an ultrasonographic examination of the abdomen are indicated (e+,, -). These tests can be performed quickly and with negligible distress to the patient. $t should be borne in mind, howe%er, that these tests are not %ery sensiti%e or specific. .onditions affecting the female reproducti%e tract, such as adnexitis, symptomatic o%arian cysts, or extrauterine pregnancy, are common causes of right lower quadrant pain/ thus, a properly performed gynecological examination is recommended, combined with an endo%aginal ultrasonographic examination, as long as it can be performed in an acceptably

(). then plain abdominal and chest x!rays should be obtained to determine the possible presence of free intraperitoneal air or adynamic intestinal loops (figure +) . their diagnostic %alue is limited ()..g.g.T. The specialists that are consulted to e%aluate symptoms of these types will then determine the indication for further tests such as ! 0xtended urinalysis ! 1oiding urography ! 2lain x!rays of the pel%is and spine ! 3pinal . $f the initial diagnostic e%aluation has not re%ealed any definiti%e or suspected diagnosis. e.g.short time frame (7. or macrohematuria. then a general surgeon should be consulted next. e++). renal percussion tenderness. due to right!sided di%erticulitis) or ileus. alguria&dysuria. a general surgeon should &e consulted. e. 2lain films of the abdomen should not be obtained routinely in the diagnostic assessment of right lower quadrant pain.or in the orthopedic&neurological area. The most common causes of right lower quadrant pain Surgery !astroenterology " #cute appendicitis " !astroenteritis $%acterial &iral' " (esenteric lymphadenitis $)ersinia enterocolitica infection' . it would seem more reasonable either to obser%e the History #n wo$en with right lower )uadrant %ain. 4nless these are ordered to answer a specific question. a g*necological e(a$ination often leads to the diagnosis.. The same procedure applies to patients who present with additional symptoms or findingsin the urological area. radicular or pseudo!radicular symptoms. and percussion tenderness of the spine.. $f there are right lower quadrant symptoms suggesting perforation (e. mo%ement!related pain. $f a woman with right lower quadrant pain is first seen by a gynecologist and the cause of the trouble is not definiti%ely found to be gynecological. Systematic history-taking #f the %atient has &een e(a$ined &* a g*necologist and her s*$%to$s do not a%%ear to &e due to a g*necological %ro&le$.

Differential diagnosis: the typical causes of right lower quadrant pain 4p to this point. This factor complicates the diagnostic process still further.leus " (eckel. Surgery gastroenterology . %omiting. . and cessation of defecation.lassic symptoms are nausea. classified according to the rele%ant medical specialties. ++7/ see also the diagnostic algorithm shown in diagram + ). in each specialty area there are rarer causes of right lower quadrant pain." *erforated or infected cecal pole di&erticulum " Sigmoid di&erticulitis or perforation " +rohn. we ha%e discussed the initial steps in the e%aluation of all cases of right lower quadrant pain. 8e will now describe its %arious typical and common causes. *lain a%dominal x-ray Plain fil$s of the a&do$en should not &e o&tained routinel* in the diagnostic assess$ent of right lower )uadrant %ain.ulcerati&e colitis " +arcinoma of the colon " . not all of which can be listed here.s di&erticulum !ynecology " #dnexitis tu%o-o&arian a%scess " /xtrauterine pregnancy " Torsion of an o&arian cyst 0rology " +ystitis pyelonephritis " 0rolithiasis " Tumors of the urinary tract 1eurology orthopedics " Radicular pseudoradicular symptoms of disc prolapse or protrusion " +oxarthrosis " Sacroileitis " Herpes 2oster patient further and reassess at close inter%als or to proceed right away to computeri5ed tomography. The abdominal pain is typically diffuse and poorly locali5able at first.ppendicitis is probably the most common cause of right lower quadrant pain. :oreo%er. until it becomes concentrated in the right lower quadrant (e)). $t should be borne in mind that patients9 complaints are highly %ariable and often atypical.. .s disease. depending on the se%erity of the symptoms (6+.

The same holds for the digital rectal examination (e+<.+nless the* are ordered to answer a s%ecific )uestion. 2atients with appendicitis may also ha%e the following ! =lumberg9s sign contralateral rebound pain (e). +@). 2atients generally present to medical attention after ha%ing suffered abdominal pain for + or < days. $f the typical symptoms and signs of appendicitis are present. ! ?o%sing9s sign pain when manual pressure is applied to the ascending colon in a retrograde direction. the patient should be taken to surgery. This is a classic finding of retrocecal appendicitis.%%endicitis is the $ost co$$on cause of right lower )uadrant s*$%to$s. the correct diagnosis can be established and a decision to operate can be made on clinical grounds alone.. including percussion tenderness. because of its cost and the radiation exposure associated with it. 3tudies ha%e not confirmed the hypothesis that the difference between the axillary and rectal temperatures is of diagnostic significance (+<. their diagnostic value is li$ited. *) ! The psoas sign pain on lifting of the straightened right leg against resistance. e+<).T as a routine in%estigation in all patients with acute right lower quadrant pain cannot be Bustified. 'urther information can be obtained by ultrasonography (concentric ring sign. :odern computeri5ed tomography enables appendicitis to be diagnosed with high sensiti%ity and specificity (++. and local guarding . e+@). $n general. +4. rebound pain.Aonetheless. The protean manifestations of appendicitis make it impossible to state uni%ersally . 0xamination usually discloses locali5ed lower abdominal pain and peritoneal signs at :c=urney9s or >an59s point. 'e%er may or may not be present. howe%er. free fluid) and by laboratory testing (leukocytosis) (e+. +<). whene%er appendicitis is strongly suspected. the use of . -. though it is in any case an integral part of a thorough physical examination of the abdomen.pplicable rules about when to operate. Diagnostic assessment . The suspicion of appendicitis is .

ppendicitis can usually be distinguished from bacterial or %iral gastroenteritis on clinical grounds (the latter is associated with recent consumption of possibly tainted food. should be performed in atypical cases and when yet . absence of peritoneal signs and guarding. diarrhea. . the diagnosis and the indication for surger* can &e esta&lished on clinical grounds alone.rohn9s disease. weight loss. a history of perianal fistulae. and ulcerati%e colitis generally do not produce peritoneal signs or guarding unless a perforation has occurred. and a prior appendectomy. #ppendicitis #f the clinical assess$ent reveals entirel* t*%ical findings of a%%endicitis. Dften.usually based on the clinical findings (local peritoneal signs and guarding) but can also be deri%ed from ancillary tests. .T (e+. Castroenteritis.olonoscopy may be used for the definiti%e diagnosis of chronic inflammatory bowel disease but is not useful as an emergency diagnostic test because it requires prior bowel preparation with appropriate rinsing solutions. these diseases can be distinguished from appendicitis by ultrasonography or . such as plain x!ray of the abdomen with an emptied gastrointestinal tract and computeri5ed tomography.hronic inflammatory bowel diseases such as . . -. ?ight lower quadrant pain is an . %omiting. and hyperperistaltic bowel sounds 6+<7)..rohn9s disease and ulcerati%e colitis can produce symptoms and signs resembling those of acute gastroenteritis/ these entities should be suspected in patients with chronically recurring diarrhea. e+@). . To the best of the authors9 knowledge. especially typical feature of terminal ileitis (e+4). 'urther ancillary tests. it is common practice in most hospitals to rely more on the clinical findings than on ancillary tests in cases of doubt. The three steps in the diagnostic assessment of right lower quadrandt pain ! -istor* ! Ph*sical e(a$ination ! #s a%%endicitis sus%ected.

>aparoscopy often enables immediate treatment of the problem. The known contraindications to laparoscopy should be borne in mind. and imaging studies. the most important differential diagnoses of appendicitis are acute adnexitis&salpingitis. which is particularlylikely to arise in the right hemicolon in patients of . Tumors of the right hemicolon. . and parametritis (e+)). classically occurring in a patient who has pre%iously had an appendectomy (+7). $nfection of a :eckel9s di%erticulum is a special type of di%erticulitis that is only rarely correctly diagnosed preoperati%ely (e+-). chronic course/ the affected patients may also complain of weight loss. is often bilateral. . /T or %lain fil$ of the a&do$en should &e o&tained if the constellation of clinical findings is at*%ical. $n the surgical!gastroenterological area. lack of flatus or defecation) ! . e. 0%en sigmoid di%erticulitis can present in the right lower quadrant if a large sigmoid loop is present. abscesses in the adnexal region. This fact indicates the maBor importance of gynecological conditions in the differential diagnosis of appendicitis (7). pain often exacerbated by the 1alsal%a maneu%er). $t characteristicallyarises in sexually acti%e women. for example. another possible cause of right lower quadrant pain is di%erticulitis (e+*). laboratory tests. "iagnostic laparoscopy can also be used instead of laparotomy when an acute disease process in the abdomen has already been successfully diagnosed on the basis of the clinical examination. howe%er.dhesion!related pain. Dther diseases causing right lower quadrant pain usually ha%e further accompanying symptoms that can aid in the differential diagnosis.dhesion ileus (symptoms of ileus.g. . e+(). altered bowel habits.other possible diagnoses are suspected (e+@)..ppendicitis is suspected and then not confirmed at surgery more often in women than in men (+4. and blood in the stool. $f the clinical examination and ancillary tests do not pro%ide a clear answer and the abdominal symptoms and signs are so se%ere that the presence of a life!threatening condition cannot be ruled out with certainty. !ynecology . by laparoscopic appendectomy. and is sometimes accompanied by abnormal %aginal bleeding or discharge. acute adnexitis often presents inatypical fashion and can then be definiti%ely diagnosed only by laparoscopy.sian extraction (+*). usually cause right lower quadrant pain only 3urther diagnostic testing Right lower )uadrant %ain is a t*%ical $anifestation of diseases affecting the ter$inal ileu$. including a history of extensi%e abdominal surgery (+(). after a long.mong the %arious types of infectious&inflammatory change coming under the heading of Fpel%ic inflammatory diseaseF (2$"). diagnostic laparoscopy should be performed (e+7). 3ome other conditions causing pain in the right lower quadrant without peritoneal signs are ! :esenteric lymphadenitis due to infection with Eersinia enterocolitica (+-) ! $nguinal hernia (palpable. >ike appendicitis.

0xtrauterine pregnancies are often found in the o%iducts but can also be located in an o%ary or in the peritoneal ca%ity.n adnexal mass is seen/ sometimes the fetal heartbeat can be seen as well. ultrasonography usually re%ealsa fairly large o%arian cyst (G * cm). causing a potentially life!threatening intra!abdominal hemorrhage (e<+). pain on passi%e mo%ement of the cer%ix. 1aginal ultrasound can re%eal the diagnosis if the o%iducts are markedly distended by pus or blood (pyosalpinx or hematosalpinx) (e<. 4nless an abscess has formed. in connection with intense physical acti%itysuch as sport or dancing. e. Torsion of an o%arian tumor or cyst. or cyst rupture. The uterine ca%ity is usually empty e%en though the endometriumis greatly thickened. and&or uterine tenderness to palpation. The Fpseudogestational sacF that is sometimes found in the uterineca%ity by ultrasonography makes an intrauterine pregnancy more difficult to rule out. >aboratory testing only re%eals ele%ated inflammatory parameters. can also cause acute right lower quadrant pain.nother gynecological disease that can cause acute right lower quadrant pain is ectopic pregnancy (figure <). 0xtrauterine pregnancy often becomes symptomatic when it perforates. The diagnosis can often be made with endo%aginal ultrasonography (<. . usually not palpable. 2atients may ha%e a history of bouts of adnexitis or a prior extrauterine pregnancy. $ts manifestations include ! 3econdary amenorrhea ! . la&orator*.g.). "oppler ultrasonography re%eals diminished or absent blood flow in the affected o%ary (<+).bnormal %aginal bleeding. positi%e pregnancy test ! Aormal inflammatory parameters ! . .). There may be lower abdominal guarding. $n many cases. 2alpation generally yields no definiti%e findings. the o%iducts are often not especially thickened and therefore Diagnostic laparoscopy Diagnostic la%arosco%* can &e %erfor$ed when the foregoing clinical. acute adnexitis arises in connection with the use of an intrauterine contracepti%e de%ice ($4" or spiral) (+)).. $n cases of torsion.$n many cases. This entity causes %ery se%ere pain that generally arises quite suddenly. . and i$aging tests all %oint to an acute intra a&do$inal %rocess.

contrast!enhanced . but it can ne%ertheless be the presenting symptom of pyelonephritis. and d*s or alguria. 0rology ?ight lower quadrant pain is rarely the maBor clinical finding of an acute urological illness. or a tumor of the urinary tract. renal percussion tenderness. $n all of these cases. urological consultation should be obtained. $f any of the abo%e manifestations are present in a patient with acute right lower quadrant pain. like urological conditions. pre%ious episodes of mid!cycle pain) can yield important diagnostic clues (<). generally do not cause isolated right lower quadrant pain/ rather. including common . including macro! or microhematuria.T or micturition urography can be performed to complete the diagnostic e%aluation (e<<). laparoscopy is a goodoption (e+)) that should be considered if the patient wishes to a%oid the radiation exposureassociated with .oxarthrosis ! 3acroileitis ! $nter%ertebral disc prolapsed ! >umbago. 0rological causes Lower a&do$inal %ain can also &e due to urological causes such as $acro or $icrohe$aturia. and dys! or alguria.T. $f the urologist also suspects a urological condition. urinary colic. The absence of fe%er and laboratory changes indicating inflammation is a further criterion by which these processes can be distinguished from an acute infectious&inflammatory disease in the abdomen. .8hene%er the clinical findings lead to no clear diagnosis. cystitis. 4rthopedics neurology Drthopedic and neurological conditions. o%ulation itself can sometimes cause acute lower abdominal pain. >eukocytosis is absent. renal tenderness. carefully obtained history (last menstrualperiod. e%en if the menstrual cycles are regular. Rare causes of right lower quadrant pain There are a large number of rarer causes of right lower quadrant pain. The pain is classically associated with mo%ement and can be deliberately manually pro%oked at its site of origin (e() when it is due to conditions such as ! . and abdominal ultrasonography is unremarkable.$n premenopausal women. and particularly in young womenwho may be suffering either from appendicitis or from adnexitis. it is usually accompanied by other symptoms or signs pointing to the urological origin of the problem (<<). Dbstructions to the flow of urine can often be seen when ultrasonography is performed as part of the emergency diagnostic e%aluation. the pain is typically accompanied by other symptomsand signs.

arsenic) and familial hyperlipoproteinemias with hypertriglyceridemia. modern radiological studies should be performed as soon as possible. . cecal %ol%ulus (<*). 4&er&iew ?ight lower quadrant pain can be due to a large %ariety of diseases whose causes must be diagnosed and treated by physicians from a number of different specialties.&do$inal %ain is onl* rarel* due to a $eta&olic distur&ance or s*ste$ic $eta&olic disease.iliac artery aneurysm (<@).. Thus. further manifestations of the disease should be sought. because delays in treatment lead to excess morbidity and mortality. . 8hen poisoning is suspected. change of the color of the urine to dark red on exposure to light is the classic diagnostic criterion. 'urther systemic diseases that can mimic a local abdominal disturbance include hea%y metal poisoning (lead. manifestations are sufficiently typical. These entities can usually be recogni5ed by . this disease is not necessarily the cause of the abdominal pain. the physician should attempt to determine the nature of the exposure/ in lipid metabolic disorders. xanthomatoses or lipemic retinitis (e<@).g.T or by laparoscopy. extensi%e ancillary diagnostic testing can often be dispensed with. the treating physician should always take care to exclude other causes. 0%en if the patient is known to suffer from a systemic metabolic disease. $f the clinical Rare causes . and intussusception (+)). a rapid and interdisciplinary e%aluation is essential. . 8hen the cause of acute right lower quadrant pain is not immediately e%ident. as these will make an important contribution to the diagnostic process. . infarction of the cecal pole (<4). "iabetic ketoacidosis is easily distinguished from an infectious or inflammatory process in the abdomen by the history and by simple laboratory tests.cute intermittent porphyria is exceedingly rare and often hard to diagnose because its abdominal manifestations are combined with mental changes and %ariable neurological manifestations.bdominal pain is only rarely caused by a systemic metabolic disease or temporary metabolic derangement. thallium. $f the findings are unclear. howe%er. e. because an intra!abdominal cause may be present as well.